PELVIC ORGAN PROLAPSE POP

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PELVIC ORGAN PROLAPSEPOP

• HESHAM A F SALEM MD
• ALEX. UNIV.

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POP

• DESCENT OF ANY OF THE PELVIC ORGANS BELOW ITS
  NORMAL POSITION IN THE PELVIC CAVITY .

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POP

• One of the commonest presentations in
  gynecological practice.
• 11.1 of 80 years old women have been exposed to
  the risk of POP . Olsen 1997.
• 22.7 per 10000 women had one operation for POP
  in one year in the discharge list of American
  hospitals .
• SUBAK 1998 has estimated the direct cost of POP
  surgery to be 1012 million US / year in the
  USA.

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POP

• MORE THAN 50 OF WOMEN UNDERGOING SURGERY FOR
  POP PERFORMS MORE THAN ONE PROCEDURE IN SINGLE
  SURGERY .
• ARAH RINGOLD ET AL 2005

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POP

• 29.2 RECURRENCES .
• Scaring and fibrosis produced by conventional
  surgery restores only 50 of tissue strenghth
  .COSSON ET AL 2003 .J GYN OBST BIOL REP .
• 58 recurrence rate after I year of surgery in a
  prospective study . whiteside et al 2004
  AM J OB/GYNE.
• GOAL OF TREATMENT IS TO RESTORE ANATOMY ANF
  FUNCTION .

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Rectocele and mucosal prolapse of the anus
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Complete rectal and uterine prolapse
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POP

1. ANTERIOR URETHRA , BLADDER . (central and
   lateral )
2. CENTRAL UTERUS ,CERVICAL STUMP ,VAGINAL VAULT
   .
3. POSTERIOR RECTUM ,LOOPS OF INTESTINE (low ,mid
   , high) .

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Anatomy

• In upright or sitting position
• Bladder, upper two-thirds vagina and rectum lie
  in a horizontal axis
• Urethra, distal one-third vagina and anal canal
  are vertical in orientation
• Pelvic floor is horizontal and is like a hammock
  levator plate

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THE PELVISWHAT IS SPECIAL ABOUT IT?

• NARROW BONY CONTAINER .
• CONTAINS 3 DIFFERENT DISTENSIBLE SYSTEMS .
• THEY ARE DISTENSIBLE TO MANY MULTIPLES OF THEIR
  ORIGINAL SIZES .
• 3 HIGH PRESSURE POINTS .
• ONE LOW PRESSURE (low resistence ) SYSTEM (
  vagina ,anal canal, urethra ) .

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THE PELVISWHAT IS SPECIAL ABOUT IT

• THE 3 SYSTEMS ARE IN VERY CLOSE PROXIMITY TO EACH
  OTHER .
• THE 3 SYSTEMS ARE KEPT IN PLACE AND IN PROPER
  INTERRELATIONS BY THE ENDOPELVIC FASCIA .
• WHEN ONE SYSTEM WORKS THE OTHER 2 ARE NEGATIVELY
  AFFECTED .

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THE PELVISWHAT IS SPECIAL ABOUT IT

• ONE HIGH PRESSURE SYSTEM CAN INVADE THE OTHER LOW
  PRESSURE ONE IF THE SUPPORTING ENDOPELVIC FASCIA
  IS TORN OR LOST .
• THE PELVIC DIAPHRAGM ACTS ONLY AS A SOUTH GATE
  FOR THE PELVIS, AND HAS NOTHING TO DO WITH THE
  INTERRELATIONS BETWEEN THE DIFFERENT SYSTEMS .
• USING THE MUSCLE TO CORRECT MALRELATIONS BETWEEN
  ORGANS NEEDS REVISION .

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NORMAL DEFECATION
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Anatomy

• The levator complex is composed of the
  pubococcygeus, the iliococcygeus, and the
  coccygeus muscles. The most medial fibers of the
  pubococcygeus make up the puborectalis. These
  fibers loop around the posterior aspect of the
  rectum and create an anterior displacement of the
  rectum known as the anorectal angle.
• The pelvic surface of the levator complex is
  innervated by sacral efferent from S2 through S4.
  The inferior surface is supplied by the perineal
  and inferior rectal branches of the pudendal
  nerve.
• The levator ani musculature is attached to the
  inner sides of the bony pelvis by a condensation
  of pelvic fascia called the arcus tendineus.

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Supporting ligaments and fascia

• The urethropelvic ligament is a fibrous band of
  connective tissue that lines the undersurface of
  the bladder neck and attaches laterally to the
  arcus tendineus. The urethropelvic ligament
  provides the major support to the bladder neck
  and proximal urethra. Laxity of the urethropelvic
  ligament results in SUI.

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Supporting ligaments and fascia

• The pubocervical fascia is a fibrous sheet of
  connective tissue that lines the base of the
  urinary bladder and inserts laterally into the
  arcus tendineus. An intact pubocervical fascia
  prevents the herniation of the bladder and the
  proximal urethra into the vagina. Damage to the
  pubocervical fascia may cause the bladder to
  herniate through the vagina, resulting in
  cystocele formation and SUI

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Supporting ligaments and fascia

• The cardinal ligaments arise from the arcus
  tendineus and anchor to the uterine cervix. The
  cardinal ligaments stabilize and support the
  uterus, vagina, and bladder. Weakening of the
  cardinal ligaments may cause a cystocele and
  uterine descensus.

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Supporting ligaments and fascia

• The uterosacral ligaments originate from
  condensation of the fibrous connective tissue
  overlying the sacral promontory and insert into
  the uterine cervix. The uterosacral ligaments
  stabilize the uterus in the bony pelvis.
  Weakening of the uterosacral ligaments may cause
  a prolapsed uterus or vaginal vault prolapse.

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Vaginal ligaments

• The vagina can be anatomically divided into the
  proximal, middle, and distal regions. The
  proximal segment, called the vault or cuff, is
  stabilized by the parametrium, which includes the
  cardinal and uterosacral ligaments. Uterine and
  vault prolapse are both associated with damage to
  these supportive structures.
• The mid portion of the vagina is attached
  laterally to the pelvic sidewalls by the lower
  portion of the paracolpium to the arcus tendineus
  fascia pelvis (ATFP), which creates the superior
  lateral vaginal sulcus observed during a physical
  examination.

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Vaginal ligaments

• The pubocervical fascia stretches between the
  ATFP to support the anterior vaginal wall and
  bladder. A cystocele can occur when damage to the
  pubocervical fascia in the central or lateral
  areas (or both) allows the bladder to prolapse
  into the vagina.

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Vaginal ligaments

• In a similar fashion, the posterior vaginal wall
  in the mid vagina is supported centrally and
  laterally by the rectovaginal fascia, which is
  attached to the fascia of the levator ani
  musculature. These attachments prevent the rectum
  from prolapsing into the vagina and causing a
  rectocele.

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Vaginal ligaments

• The distal vagina is firmly attached to the
  surrounding structures, including the urethra and
  symphysis pubis anteriorly, levator ani
  laterally, and perineal musculature posteriorly.
  Damage to the perineal musculature by childbirth
  or surgery are common causes of a relaxed outlet.
  

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NATURE OF PELVIC LIGAMENTS

• THEY ARE NOT TRUE LIGAMENTS .
• THEIR MAIN FUNCTION IS BALANCE OF PELVIC ORGANS .
• THEY SUSPEND PELVIC ORGANS WHEN THE LEVATOR
  SUPPORT FAILS .
• LEVATOR IS NOT REPAIRABLE NOR REPLACABLE.
• LIGAMENTS ARE REPAIRABLE OR REPLACABLE .
• LIGAMENTS ARE CONDENSATIONS OF A CONTINUM CALLED
  THE ENDOPELVIC FASCIA .

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Boat in dock analogy

• Boat- pelvic organs
• Water- levator muscles
• Moorings- Endopelvic fascial ligaments
• Problem is with the water or moorings or both
• Result is sinking of the boat
• Really the boat itself is fine

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Boat in dock analogy

• The main support for the pelvic viscera is
  provided by a group of muscles collectively
  called the levator ani. An intact pelvic floor
  allows the pelvic and abdominal viscera to "rest"
  on the levator ani, significantly reducing the
  tension on the supporting fascia and ligaments.
  These pelvic ligaments are not true ligaments and
  are simply condensations of endopelvic fascia
  covering the pelvic structures.

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Boat in dock analogy

• The pelvic floor musculature and the pelvic
  ligaments work together to provide support to the
  pelvic floor structures. Most of the weight of
  the pelvic viscera is supported by the levator
  ani, whereas the pelvic ligaments stabilize these
  structures in position, much as a ship's weight
  is supported by the water and the moorings simply
  keep the ship from straying from the dock. When
  the levator ani is damaged, excessive force is
  placed on the ligaments, creating a
  predisposition for pelvic prolapse.

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PROLAPSE

• Mutifactorial involving both neuromuscular and
  endopelvic fascial damage
• Relaxation of the tissues supporting the pelvic
  organs may cause
• Downward displacement of one or more of these
  organs into the vagina, which may result in their
  protrusion through the vaginal introitus.
• Displacement of one or more of pelvic organs into
  the rectum or onto the perineum.

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Factors promoting prolapse

• Erect posture causes increased stress on muscles,
  nerves and connective tissue
• Acute and chronic trauma of vaginal delivery
• Aging
• Estrogen deprivation
• Intrinsic collagen abnormalities
• Chronic increase in intraabdominal pressure
• heavy lifting
• coughing
• constipation

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Factors promoting prolapse

• More recently, an association between collagen
  and connective tissue disorders and pelvic floor
  relaxation has been established.
• Some vaginal prolapse conditions may even be
  caused by prior pelvic surgery. For example, a
  hysterectomy may cause an enterocele or vault
  prolapse to form if the vault is not adequately
  resuspended and the cul-de-sac is not
  prophylactically obliterated.

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Factors promoting prolapse

• A rectocele is a prolapse of the rectum into the
  vagina through a damaged rectovaginal septum. The
  most likely etiology for rectocele formation and
  perineal relaxation presumably is improper
  childbirth because these conditions are
  essentially confined to parous women.
• In some cases, a relaxed outlet may be caused by
  an inadequately or incompletely healed episiotomy
  performed at the time of childbirth.

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Factors promoting prolapse

• A cystocele is a prolapse of the urinary bladder
  into the vagina through a damaged urethropelvic
  fascia . The most likely etiology for cystocele
  formation presumably is improper childbirth
  because these conditions are essentially confined
  to parous women.

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Factors promoting prolapse

• Uterine prolapse is descent of the uterus due to
  laxity or damage of the maine uterine ligaments
  during improper childbirth .
• Pelvic organ displacements are usually the result
  of disruption of the endopelvic fascia in between
  the maine pelvic ligaments .

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STRATEGY OF TREATMENT

1. MUSCLE DEFECT .
2. FASCIAL DEFECT

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STRATEGY OF TREATMENT

• EXERCISE IS THE ONLY WAY TO STRENGHTHEN A MUSCLE
  .
• MUSCLE APPROXIMATION IS HELPFUL ONLY IN
  DIVARICATION DEFECTS .
• REPAIRE OR REPLACEMENT OF FASCIA AND LIGAMENTS IS
  THE IDEAL WAY TO CORRECT PROLAPSE .
• HYSTRECTOMY TO TREAT UTERINE PROLAPSE IS AN
  UNWISE CHOICE .

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FASCIA REPLACEMENT SURGERY

• EASIER THAN CONVENTIONAL SURGERY .
• SHORTER LEARNING CURVE .
• LESS INVASIVE .
• ORGAN SAVING . eg uterus , levator ani.
• LESS LAPAROTOMIES .
• FASTER RETURN TO USUAL LIFE ACTIVITIES .
• SOME NEW PROBLEMS HAS EVOLVED AND NEED SOME TIME
  FOR BUILDING UP EXPIERIENCE TO MANAGE THEM .
• EQUAL OR BETTER RESULTS .

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FASCIA REPLACEMENT SURGERY

• Uterine prolapse replacement of the uterosacral
  ligament by plication or mesh promontofixation ,
  sacrospinous fixation ,P IVS .
• Rectocele replacement of the rectovaginal
  fascia .
• Cystocele , urethrocele replacement of the
  pubocervical fascia and urogenital triangle .
• Gsi replacement of the pubocervical fascia by
  TOT ,TVT A IVS , TVT SECURE .

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Perineology

• Perineology is the result of the fusion between
  urogynecology and coloproctology. This
  "three-axis approach" is now becoming widely
  accepted.
• The aim of Perineology is the understanding of
  the anatomy in the respect of biomechanics and
  physiology.
• The functional state of the perineum can be
  summarized with a T.A.P.E. (Three Axis Perineal
  Evaluation).

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Perineologist

• This approach has to be interdisplinary and not
  multidisciplinary. There is only one boss who
  must be the "architect of the perineum", somebody
  who knows a lot about the anatomy and the
  physiology of the three axis.
• This new specialist is called "perineologist". He
  could be the surgeon or somebody who tells the
  surgeon what to do. The perineologist must have a
  holistic view (integration of the psychology, the
  way of life, the abdominal wall muscles... in the
  approach).

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MESSAGE

• REPAIR SHOULD BE COMPREHENSIVE .
• MUSCLE EXERCISE IS IMPORTANT .
• TORN LIGAMENTS MAY BE REPAIRED OR REPLACED .
• WE ARE IN NEED OF A PERINEOLOGIST WHO CAN HANDLE
  THE PROBLEM OF POP IN A WIDER ANGEL OF VISION .

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THANK YOU